19567APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Add mss:
PERMIT NO.
/oco A f, A'- v
19567
sora a a : Phone,
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
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con dpaNam.: Lie. No-
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BUILDING-ELECTRICALPLUMBING-MFG NICAL
CATEGORY
CONTROL 0
Architect/Engineer. Lk. Nre
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address
PERMITISSUANCE
❑ ❑ ❑ }�
Y -V
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lam licensedunder provolousof Chapter 9(commroc
APPLIANCES-RESIDENHAL
]OB DESCRR'1 ION
PANELS
ingwith Section 7fsXBof Dlvlslmn3ofthe Bualneasand ProfessionaCode, and my
licamalelL ddfd,��i
Liere ClaMET# _30 i
Data 5-4 Co:otch,
201-1000 AMPS
ARCHTECTS DECLARATION
I understand my piam shall be used u public mounds.
OVERHBOAMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
SPECIALCIRCUIT/MISC
OWNER -BUILDER DECLARATION
I herebyatfirmthat I am exempt from the Contractor's License Law forthe
TEMP. METER OR POLE INST.
following reason.(Section 70115, Business and Professions Code: Any city or
cauntywhlchrequb apermittommtr Malter,bnpmve,de=llsh,orrepair
anystructure priorto its Issuance, also requlreathe applicant for such permit to
file a signed statement that he Is licensed pursuant to the provisions of the
POWER DEVICES
SWIMMING POOL ELECTRIC
Contractors Liceree Law (Chapter 9(commencleg with Section 7000) of Divi-
Men 3 of the Business and ProfesslonsCods) orthat he is exempttherefromand
VALUATION
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit subjectltheappBeant to a civil penalty of nut mom than
OUTLETSSWTTCHFSFIXTURFS
five hundred dollars ($500).
❑ 1, as owner of the property, or my employees with wage as their sole
NEWRESIDENTIALELBCTReSQFT.
STORIES
TYPE CONSTRUCTION
compensation, will do the work, and the structure Is not intended or offered for
sale fSec. 7614, Business and Professions Code: The Conlradols License law
does not apply to an owner of property who W Ilds or improves thereon and
who doessuch work himaelforthrough his own employees, provided that such
OCC.GROUI'
RES. UNITS
Improvements are not Intended oroffered forvle. If, howevep thebullding or
TOTAL:
Improvement esold withinoneyearofcompldlonlhe owner-bullderwlll have
the—burden of proving that he did not Wild or Improve for purpose of sale.).
I, as owner of the property, am exclusively =trading with licensed
contractors to construct the project (Sec. 7044, Business and Professions Code:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
qPN
PERMIT ISSUANCE
The Contractor. License law don not apply to m owner a property who
Wilda or lmprovn thereon, and who contracts for such p(ojech, with a
codor(s) licensed pursuant to the Contractor's License Law.
L_j I am exempt under See. B s P C for this ressumOUTSIDE
ALTER -DRAIN A VENT- WATER (EM
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRNS FLOOR, ROOF, AREA, CONED.
AI
SANITARY Y N_�
RECEIPT R
Owner Date
here WORKMAN COMPENSATION DECLARATION
ofby affirm that I have a certificate of consent to self -Insure, or a
certificate of Workhes''Coommperealtonlreu�rrance or a certifksd copylhermf(Sec.
3800, lab CJ
i� �_�
FIXTURES PER TRAP
SCHOOL TAX Y N_
RECEIPT N
GAS EA. SYSTEM -1 INCA OUTLETS
PARKFEE Y N
RECEIPT Y
1WICY P Ll/ /
Com env A� L
GAS EA. SYSTEM -OVER 4 (EA)
BNLDING DIVISION FEES
Certified cFpy R hereby famished.
E]Certified copy Is filed with the city Inapedlon division.
CREASE/INDUSTRLWASIEINTFRCEPTOR
PLANCHECIC FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA 200FI
COMPENSATION INSURANCE
(This sedlmn need rad W emnplded Rthe permit isfor onshundred dollen
(810()orless.)
I certify that In the performance of the work forwhlch this permit in issued,
Date Recd tit
WATER HEATER W/VFM/ELECTR
ENERGY FEE Y_ N_
WATER SYSTEM/TREATING
I shall not employ any person In any runner m as to become subject to the
Worker' Compensation laws of California. Date
PAID
NEW RE9DEN77AL PLMB. SQ.FT.
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provolom of the Labor
Dale Recei til
TOTAL:
BUILDING FEE
Code, you most forthwith comply with such provisions or this permit shall W
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby affirmthat there is aconstmtton lendlegagency, forthe perform-
ance of the work forwhlchthbparmk l91ns�aa� (Sac.3097,Cie.C.)
I<dersNama �1[LINP/`ria4ai.YILCCJOC
I.cder'a Addnms
Imnlfythatlhavemadthbappliationandgalelhattheabove lnformatlon
is correct. I agree m comply with all city and countyordinances and state laws
TOTAL
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
_
w�
Q.n, MECHANICAL PERMIT FEE
ppgMLL ISSUANCE '�^ty�D
FEES PAID-.
relating to building construction, and hereby authorize representatives of this
city to enter upon the above-mentioned property fee inspection purpose.
ss the City of Cupertino accrue
(We) agree to save, indemNty and keep harmles which
against Ilab Bt@s, pdgm<nts, cosband expense which may In any way accrue
ALTERORADDTOMECH. _106
Date Receiptfl
AIR HANDLING UNIT CTO 10,000 CFM)
SUBTOTAL:
aga Wt Ity In roe ce of the gaming of this permit.
'
AIRFiANDLINGIINIT (OVER 10,000CFM) l Ox(b
CONSTRUCTION TAX
Sigwmre of Applicant/C&tnctor Data
EXHAUST I IOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,(1110 BM
Date Recej IN
Will the applicant or future Wilding occupant store or handle havardous
materinl as defined by the Cupertino Munidpal Code, Chapter 9.17, and the
Health and Safety Code Sed1on 25532(a)I
❑ Yea , MN.
Will the applicant or future building occupant use equipment or devices
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN(SINGLE RESID)ISDATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District?
Yes n No
thavereadiheh.,U-.usmaterialsrequimc ntsunderChapter6.95of
rl"1R41f5
JUL U2 1�5
ROLLER -COMP CHIP OR 1M000 BTU)
BOILER -COMP (OVER 100,000 BTU)
the California Health k Safety Code, Sections 25505, 25533 and 25534. I
understand that lithe building does not currently have a tenant, that it is my
responsibility, to aaify the occupant of the requirements which most be mart
as{ pp'�'� .y,
Pilo Vti 4YQBI RQO
NEW RESIDENTIAL MECH. SQ.Fr.
prior to Issuance of a Certificate of Occupancy.
��Wy s�V�l�.;
ISSUED BY:"M
Owner or authotized agent Data
TOTAL: s
OFFICE COPY